Eye Examinations

Note: Vision plans available through the Federal Employees Dental and Vision Insurance Program (FEDVIP) are separate from the TRICARE vision coverage. 

Routine Eye Exams

Routine eye exams are a limited benefit under TRICARE and coverage differs by beneficiary category. A routine eye exam may include but is not limited to: refractive services, ocular alignment and red reflux, dilation and external examination for ocular abnormalities. The covered CPT® codes for routine eye exams are: 92002, 92004, 92012, 92014, and 92015.

• For all beneficiaries, the primary diagnosis on the claim should be routine vision screening.
• For diabetic beneficiaries, the primary diagnosis on the claim should also be routine vision screening, with diabetes listed as a secondary diagnosis. Failure to include the routine diagnosis or using an evaluation and management (E&M) procedure code may cause the claim to process as a diagnostic eye exam. 

Routine diagnoses may include: exam of eyes and vision (with or without abnormal finding), myopia, degenerative myopia, hypermetropia, astigmatism (regular, irregular or unspecified), anisomentropia, aniseikonia, presbyopia, paresis or spasm of accommodation, unspecified order of refraction or visual discomfort.

Preventive Services Cost Information

TRICARE Prime (excluding TRICARE Prime Remote)

• Eye exams are generally provided at a military hospital or clinic. An approved referral from Health Net Federal Services, LLC (HNFS) is required for any civilian care.

TRICARE Prime Remote

• TRICARE Prime Remote active duty service members (TPRADSMs) may receive one routine eye exam annually (once every 12 months) by a network or non-network ophthalmologist or optometrist without an approved referral.
    

TRICARE Prime/TRICARE Prime Remote with an assigned primary care manager (PCM) (including TRICARE Young Adult Prime)

• One routine eye exam every two years (24 months) for beneficiaries ages three through five. (For example, if a child is three years old and has an eye exam on July 15, 2019, the next covered exam would be on or after July 15, 2021, and before his or her sixth birthday.)
• Starting at age six, one routine eye exam annually (once every 12 months).
• No authorization or referral required if services are performed by a network optometrist or ophthalmologist. (Authorization is required if seeing a non-network provider or Point of Service charges will apply.)
• No copayment if seeing a network provider (or non-network provider, if authorized). 

TRICARE Prime Remote without an assigned PCM

• One routine eye exam every two years (24 months) for beneficiaries ages three through five. (For example, if a child is three years old and has an eye exam on July 15, 2019, the next covered exam would be on or after July 15, 2021, and before his or her sixth birthday.)
• Starting at age six, one routine eye exam annually (once every 12 months). 
• No authorization or referral required if services are performed by a network optometrist or ophthalmologist. (Authorization is required if seeing a non-network provider or Point of Service charges will apply.)
• No copayment if seeing a network provider (or non-network provider, if authorized). 

TRICARE Select (including TRICARE Reserve Select and TRICARE Young Adult Select)

• One routine eye exam every two years (24 months) for beneficiaries ages three through five. (For example, if a child is three years old and has an eye exam on July 15, 2019, the next covered exam would be on or after July 15, 2021, and before his or her sixth birthday.)
• Starting at age six, one routine eye exam annually (once every 12 months). 
• No authorization or referral required to see a network or non-network ophthalmologist or optometrist.
• Applicable cost-shares and deductibles apply if seeing a non-network provider.
   

TRICARE Prime (including TRICARE Young Adult Prime)

• One routine eye exam every two years (once every 24 months) is covered for ages three and older. (For example, if the beneficiary had an eye exam on July 15, 2019, his or her next covered exam would be on or after July 15, 2021.)
• Routine eye exams are covered for beneficiaries with diabetes. The claim should include a routine vision screening diagnosis as the primary diagnosis and a diabetes diagnosis as secondary.
• No authorization or referral  required if the service is performed by a network optometrist or ophthalmologist. (Authorization is required if seeing a non-network provider or Point of Service charges will apply.)
• No copayment if seeing a network provider (or non-network provider, if authorized).

Note: The two year requirement between routine examinations will start on the date of the eligibility change for beneficiaries who recently transitioned from active duty to retiree status. (For example, a Prime retiree or retiree family member will be eligible for a routine eye examination in the first year of the status change regardless of whether or not an examination was performed in the previous year under ADFM eligibility status.)

TRICARE Select (including TRICARE Retired Reserve and TRICARE Young Adult Select)

• Routine eye exams are not covered for TRICARE Select beneficiaries ages six and older. The following requirements/limitations apply to beneficiaries ages three through five:
  • One routine eye exam every two years (24 months) for beneficiaries ages three through five. (For example, if a child is three years old and has an eye exam on July 15, 2019, the next covered exam would be on or after July 15, 2021, and before his or her sixth birthday.)
    
  • No authorization or referral required.

Non-Routine (Diagnostic) Eye Exams

TRICARE Prime and TRICARE Prime Remote beneficiaries require an approval from HNFS for all diagnostic eye exams by network or non-network optometrists or ophthalmologists. TRICARE Select beneficiaries do not require an approval from HNFS.

TRICARE covers diagnostic exams for the treatment of a confirmed or suspected eye condition, such as diabetes or glaucoma. A diagnostic exam may be billed with E&M procedure codes such as 992xx, along with the appropriate diagnosis code (other than a routine vision screening diagnosis code) identifying the beneficiary’s eye condition. A diabetes diagnosis could be the primary or secondary diagnosis. Diagnostic exams can be billed with eye exam CPT codes 92002, 92004, 92012, 92014, 92015, or the E&M codes.

CPT codes 99172 (visual function screening) and 99173 (visual acuity screening) are examinations considered to be an integral part of an office visit or well-child visit. CPT codes 99172 and 99173 cannot be separately reimbursed when billed with a well-child or E&M office visit (99381-99397), regardless of whether a -59 modifier is used.

TRICARE does not cover routine contact lens services or contact lens fittings provided during a routine eye exam. Coverage for non-routine contact lens services requires authorization. See eyeglasses or contact lenses for additional information.

Vision screenings for newborns zero to 24 months of age, regardless of beneficiary category, are covered when provided by the PCM during routine well-child examinations.

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